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INSIDE THE CURRENT ISSUE |
August 2014 |
Infection Prevention
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IP Update |
Malnutrition screening of hospital patients common but hospitals failing
on nutrition care
A new study
gives hospitals overall good marks for conducting nutrition screenings
within 24 hours of a patient’s admission, but finds that many need to
improve other practices to be more effective.
The study,
conducted by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)
and published today in A.S.P.E.N’s Nutrition in Clinical Practice
journal, found that while most respondents said that screening patients
for malnutrition was being done in compliance with The Joint Commission
mandate of 1995, fewer than half were familiar with the 2012 Consensus
Statement from the Academy of Nutrition and Dietetics/A.S.P.E.N., which
recommends specific markers and characteristics for diagnosis of
malnutrition.
"Nutrition
is a key component of any patient’s overall health and of their
post-hospitalization recovery," said the study’s co-author Peggi Guenter,
PhD, RN, A.S.P.E.N.’s Senior Director of Clinical Practice, Quality, and
Advocacy.
A lack of
clinician participation in the nutrition care process along with an
inconsistent knowledge and use of available tools and insufficient
training of caregivers to identify and treat malnutrition in patients
were also found to be a problem among hospitals.
The survey
authors call for professional medical societies to further educate their
members on the issue of malnutrition and for additional studies and
audits of existing practices to determine ideal practices for nutrition
care plans. A.S.P.E.N. also believes that the results of this study
support the need for a nationally standardized approach to nutrition
assessment, diagnosis, and care.
Time of day crucial to accurately test for diseases
Researchers
from the University of Surrey and The Institute of Cancer Research,
London, investigated the links between sleep deprivation, body clock
disruption and metabolism, and discovered a clear variation in
metabolism according to the time of day. The finding could be crucial
when looking at the best time of day to test for diseases such as cancer
and heart disease, and for administering medicines effectively.
The results
showed that metabolic processes are significantly increased during sleep
deprivation. 27 metabolites, including serotonin, were found at higher
levels in periods of sleep deprivation compared to levels during sleep.
Lead author
Professor Debra Skene from the University of Surrey, said: "Our results
show that if we want to develop a diagnostic test for a disease, it is
imperative to take the time of day when taking blood samples into
account, since this has a significant effect on metabolism. This is also
key for administering medicines and determining when they will be at
their most effective." |
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Nutrition quality, safety drive
optimal outcomes
by Kara Nadeau Della Vecchia
O ptimal
patient nutrition is key to achieving successful clinical outcomes but the
process of delivering nourishment in any setting – acute care, home care,
long-term care – is one that is often complex and open to the risk for human
error. In this article, Healthcare Purchasing News explores
some of the top trends in enteral and parenteral nutrition delivery, and
highlights products designed to improve patient care quality and safety.
Preventing tubing misconnections
Envision a patient and the many tubes and
connections that clinicians use in the course of providing his/her care,
including those for administration of intravenous (IV) fluids, oxygen,
enteral nutrition, and epidural pain control. Now consider that the
small-bore or "Luer" connectors used to link components (e.g. an oxygen tube
to a nebulizer or an IV line to a central venous catheter) are compatible
with any delivery system, and it becomes clear how easy it is for a
clinician or other caregiver to mistakenly link the wrong device to the
wrong delivery site.
According to the Joint Commission, common tubing
misconnection errors include:
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Intravenous infusions connected to epidural lines, and epidural
solutions (intended for epidural administration) connected to peripheral
or central IV catheters.
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Bladder irrigation solutions using primary intravenous tubing connected
as secondary infusions to peripheral or central IV catheters.
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Infusions intended for IV administration connected to an indwelling
bladder (foley) catheter.
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Infusions intended for IV administration connected to nasogastric (NG)
tubes.
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Intravenous solutions administered with blood administration sets, and
blood products transfused with primary intravenous tubing.
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Primary intravenous solutions administered through various other
functionally dissimilar catheters, such as external dialysis catheters,
a ventriculostomy drain, an amnio-infusion catheter, and the distal port
of a pulmonary artery catheter.1
The U.S. Food and Drug Administration (FDA) points
out that, "in particular, misconnections with enteral feeding tubes and
solutions have been associated with death and serious injury."2
To address this often underreported but serious
patient safety issue, the FDA, other regulators, manufacturers, clinicians,
and healthcare industry associations have come together in a collaborative
manner with the International Organization of Standardization (ISO) and the
Association for the Advancement of Medical Instrumentation (AAMI) to develop
new ISO standards that require small bore connectors to be compatible only
with the patient care delivery devices for which they are intended.
The initiative is being rolled out in a phased
approach, with the industry first tackling small bore connectors for enteral
nutrition delivery. Manufacturers of enteral small bore connectors from
across the globe have come together to form the
Global Enteral Device
Supplier Association (GEDSA), a non-profit trade association, through which
they have collaborated to develop a universal, standardized connector design
that will replace all existing enteral nutrition connector systems.
Designated the "ENFit Connector," GEDSA anticipates this new design will be
an approved draft international standard by the end of the year, and a final
published standard sometime in 2015. The new connectors will be introduced
into the healthcare marketplace in the U.S., Canada and Puerto Rico late
2014/early 2015 and rolled out to other markets starting in Q3 2015.3
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Tom Hancock |
"These new, safer connectors have been years in
the making. They have been carefully tested through a rigorous
misconnections assessment, human factors and usability studies, and a robust
risk assessment. We are excited to finally introduce the ENFit connector to
help address tubing misconnections," said Tom Hancock, Executive Director of
GEDSA. "We’ve planned a careful, methodical transition to these new
connectors over time to avoid any disruption of therapy. Broad awareness and
careful preparation will be the key to a safe transition."
The
American Society for Parenteral and Enteral
Nutrition (A.S.P.E.N.) has teamed up with GEDSA, AAMI, The Joint Commission,
The Institute for Safe Medication Practices, Premier Safety Institute and
Novation to introduce "Stay Connected 2014," a comprehensive educational
campaign developed to inform and prepare the healthcare community for
impending changes to medical device small-bore connectors.4
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Peggi Guenter |
"You can imagine the education and change that
must take place among caregivers to make this transition," said Peggi
Guenter, RN, PhD, Senior Director of Clinical Practice, Quality, and
Advocacy for A.S.P.E.N. "Right now we are trying to make people aware of
these changes so their first exposure isn’t when they open a bag and
discover the new connector."
Guenter recommends that clinicians and supply
chain professionals examine what is currently being used in their
organizations, put into place "thoughtful ordering processes" to phase out
the old connector designs and phase in the new, and determine where and how
they will stock the new connectors.
"This will require a great deal of coordination
among the manufacturers, suppliers, supply chain staff and clinicians," said
Guenter.
Guenter notes that A.S.P.E.N. is working with
GEDSA on checklists for healthcare organizations with considerations on
making the switch to the new connector design. She anticipates that they
will be available on the
Stay Connected
website by the end of the summer.
Minimizing the risk for infection
As with any access site into the body, enteral
nutrition administration poses the risk for bacterial contamination and
infection. While hand washing is the first line of defense against external
contamination, manufacturers have designed enteral feeding systems with
features to reduce the risk of infection and enhance patient safety.
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Dale ACE (Access Controller for
Enteral) Connector |
For example,
Dale Medical Products, Inc. recently
introduced its Dale ACE (Access Controller for Enteral) Connector, a 100
percent closed system connector that controls fluid flow into and out of
Salem Sump, Levin, PEG/g-tubes, and select J-tubes. The connector system
remains closed to the atmosphere at all times and features a self-closing
syringe port. This design helps protect patients against infection and
shield caregivers against exposure to bodily fluids. It replaces 5-in-1
connectors and enteral feeding Y-port adapters to provide in-line feeding,
suctioning, irrigation, residual checks, and medication delivery without the
need to disconnect.
Comfort for the long term
Comfort is a primary concern for patients who must
be nourished via feeding tubes, particularly when the device must remain in
place over a long time period. To improve the comfort of patients who are
living with gastrostomy feeding tubes, and simplify enteral feeding
procedures for physicians,
Cook Medical introduced its Entuit product line
for gastrostomy feeding.
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Cook Medical’s Entuit Thrive Balloon
Retention Gastrostomy Feeding Tube |
The Entuit Thrive Balloon Retention Gastrostomy
Feeding Tube has an in-line balloon shaft that may reduce the need to
overdilate when physicians place and replace feeding tubes. The Entuit
Gastrointestinal Secure Suture Anchor Sets were designed with two options, a
standard suture anchor and an adjustable-tension suture anchor. The standard
suture anchor can be quickly tightened to secure the stomach wall to the
abdomen. The adjustable-tension suture anchor includes a locking mechanism
that enables the physician to increase tension during critical points in the
procedure and to decrease the tension later, if necessary, to make the
patient comfortable. The Entuit Start Initial Placement Gastrostomy Set
includes all of the components that are necessary to start a gastrostomy
procedure.
Nourishing the smallest patients
The National Association of Neonatal Nurses (NANN)
in its position statement, The Use of Human Milk and Breastfeeding in the
Neonatal Intensive Care Unit, states: "The use of human milk and
breastfeeding are essential components in providing optimal health for the
critically ill newborn." It is widely recognized that human breast milk (HBM)
provides myriad health benefits for neonates. HBM is easier to digest than
formula, its cells, hormones and antibodies protect against illness, and
studies have shown that HBM reduces the risk for post-neonatal death.5
While breastfeeding is the optimal delivery route
of conveying nutrition, it is not always possible to nourish neonates in the
NICU in this manner. For these infants, NANN urges healthcare providers to
"strive to initiate enteral feeds when human milk becomes available and when
the infant is stable enough to tolerate feedings." 5 The drawback
of expressing breast milk, storing it and delivering it via enteral feeding
is the loss of valuable nutrients, particularly fat (lipids).
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NeoMed’s Oral/Enteral Syringes
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NeoMed recently funded an
independent study to determine how NICU syringe choice can reduce fat loss
in human breast milk. This study concluded that eccentric tip syringes with
flat, solid polypropylene O-ring plungers had significantly less fat loss
than concentric tip syringes with conical, black elastomeric plunger
assembly.6
NeoMed’s Oral/Enteral Syringes are part of the
company’s comprehensive Enteral Safety System. Designed with a solid
polypropylene plunger head that is flatter than rubber plunger tips, NeoMed
Oral/Enteral Syringes create less surface for unwanted lipid/fat adhesion.
The offset tip ensures lipids are delivered first in a horizontally-oriented
syringe infusion pump. NeoMed’s Enteral Safety System complies with best
practice recommendations set forth by The Joint Commission and the FDA.
Reducing the risk for parenteral drug errors
It is estimated that 350,000 patients receive
parenteral nutrition (PN) during hospital stays in the U.S., with many
others receiving it in alternate care settings, such as in the home or in
long term care facilities.7
According to the U.S. Department of Health & Human
Services Agency for Healthcare Research and Quality (AHRQ), "the ordering
and administration of total parenteral nutrition (TPN) have been associated
with high numbers of medical errors and increased risk of death, especially
in pediatric patients.8" The Institute for Safe Medical Practices
(ISMP) points out how fatal 1,000-fold overdoses can occur, particularly in
neonates, when a clinician mistakenly transposes MCG and MG during the
course of administering TPN.
In 2014, A.S.P.E.N. published its Parenteral
Nutrition Safety Consensus Recommendations, noting how only 58 percent of
organizations have precautions in place to prevent errors and patient harm
associated with PN.9 Based on practices that are generally
accepted to minimize errors with parenteral nutrition administration, the
document includes recommendations on prescribing, order review and
verification, compounding, and administration. The recommendations are part
of A.S.P.E.N.’s Parenteral Nutrition Safety Toolkit, which can be found on
the organization’s website at:
www.nutritioncare.org/pnsafety.
Guenter notes, "The appropriate use of this
complex therapy aims to maximize clinical benefit while minimizing
the potential risks for adverse events. Prescribing, compounding and
administering PN in a standardized fashion goes a long way to promote
patient safety."
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Baxter’s SIGMA Spectrum Infusion
Pump
with Master Drug Library |
An example of a system designed to help promote
safety is Baxter’s DoseEdge Pharmacy Workflow Manager, which helps automate
and track the medication process from preparation through dispensing – while
providing important documentation for the entire process. To date, the
system has identified more than 1.3 million potential medication errors.*
Additionally, Baxter recently secured 510(k)
clearance from the FDA for its next-generation SIGMA Spectrum Infusion Pump
with Master Drug Library, which enables a hospital to maintain a customized
in-house library of facility-defined infusion therapy dosing parameters to
minimize the likelihood of drug errors during care. New asset-tracking
capabilities will allow hospitals to effectively locate, manage and deploy
SIGMA Spectrum inventory, helping to ensure efficient allocation of hospital
assets. Baxter will initiate a plan to launch the next-generation SIGMA
Spectrum with select healthcare facilities beginning in the summer of 2014.
References:
*Data on file; aggregated from March 2008 through
May 2014
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http://www.jointcommission.org/assets/1/18/SEA_36.pdf
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http://www.fda.gov/downloads/MedicalDevices/ResourcesforYou/
Industry/UCM218631.pdf
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http://www.stayconnected2014.org/media/pdfs/GEDSA-enteral-FAQ.pdf
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http://www.nutritioncare.org/Press_Room/2013/
A_S_P_E_N__Supports_Major_Medical_Device_Changes__
for_Improved_Patient_Safety/
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http://pediatrics.aappublications.org/content/113/5/e435.full
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http://neomedinc.com/downloads/How_NICU_Syringe_Choice_Can_
Reduce_Fat_Loss_in_Human_Breast_Milk_Low_Res.pdf
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http://www.nutritioncare.org/Guidelines_and_Clinical_Practice/
Toolkits/Parenteral_Nutrition_Safety_Toolkit/
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http://www.innovations.ahrq.gov/content.aspx?id=2323
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http://pen.sagepub.com/content/38/3/296.full.pdf+html
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